Would J.B. be a candidate for electroconvulsive therapy (ECT)? Why or why not?

Name the three most common complications of ECT.

Identify two treatments that are available for depression.

What special instructions will you give him regarding the Lexapro? Select all that apply.
a. The full effects of the medication might not be seen for 4 to 6 weeks.
b. The medication may cause nausea, dry mouth, sedation, and insomnia.
c. There are no known food interactions.
d. The herbal product St. John's wort will enhance the action of the Lexapro.
e. Taking a glass of wine at bedtime will help him go to sleep.

Which of these would be considered soft methods of suicide? Select all that apply.
a. Using a gun
b. Slashing one's wrist
c. Hanging
d. Poisoning with carbon monoxide
e. Ingesting pills
f. Inhaling natural gas

You use the SAD PERSONS scale to assess J.B.'s potential for suicide and find that he is at a 4 on the 10-point scale. J.B. tells you that he has just had general thoughts of suicide, but has not really thought about how he would do it. You recall that there are two types of suicide methods based on lethality: higher-risk or hard methods, and lower-risk or soft methods.
What immediate interventions would you carry out for J.B.?

You are working the day shift on a medicine inpatient unit. You are discussing discharge instructions with J.B., an $86$-year-old man who was admitted for mitral valve repair. His serum blood glucose had been averaging $250$mg/dL or higher for the past several months. During this admission, his dosage of insulin was adjusted, and he was given additional education in managing his diet. While you are giving these instructions, J.B. tells you his wife died $9$ months ago. He becomes tearful when telling you about that loss and the loneliness he has been feeling. He tells you he just doesn't feel good lately, feels sad much of the time, and hasn't been involved in his normal activities. He has few friends left in the community because most of them have passed away. He has a daughter in town, but she is busy with her work and grandchildren. He also tells you that he has been feeling so down the past few months that he has had thoughts about suicide.

List five of the most common signs of depression.

You are working the day shift on a medical inpatient unit. You are discussing discharge instructions with J.B., an 86-year-old man who was admitted for mitral valve repair. His serum blood glucose is $250 \mathrm{mg} / \mathrm{dL}$ (13.9 $\mathrm{mmol} / \mathrm{L}$ ) and increasing for the past several months. During this admission, his dosage of insulin was adjusted and he was given additional education in managing his diet. While you are giving these instructions, J.B. tells you his wife died 9 months ago. He becomes tearful when telling you about his loss and the loneliness he has been feeling. J.B. states he just doesn't feel good lately and feels sad most of the time. J.B. also expresses his lack of involvement in his normal activities. He has few friends left in the community because most of them have passed away. He has a daughter in town, but she is busy with her work and grandchildren. He tells you he has been feeling "depressed" the last few months with thoughts of suicide. List 5 of the most common signs of depression in the older adult.

Y.L., a $34$-year-old Asian woman, comes to the clinic with complaints of chronic fatigue, increased thirst, constant hunger, and frequent urination. She denies any pain, burning, or low-back pain on urination. She tells you she has a vaginal yeast infection that she has treated numerous times with over-the-counter medication. She works full time as a clerk in a loan company and states she has difficulty reading numbers and reports, resulting in her making frequent mistakes. She says, "By the time I get home and make supper for my family, then put my child to bed, I am too tired to exercise." She reports her feet hurt; they often "burn or feel like there are pins in them." She has a history of gestational diabetes and reports that, after her delivery, she went back to her traditional eating pattern, which is high in carbohydrates.

In reviewing Y.L.'s chart, you notice she has not been seen since the delivery of her child $6$ years ago. She has gained considerable weight; her current weight is $173$ pounds. Today, her BP is $152 / 97 \mathrm{~mm} \mathrm{Hg}$, and a random plasma glucose is $291 \mathrm{mg} / \mathrm{dL}$. The primary care provider suspects that Y.L. has developed type $2$ diabetes mellitus (DM) and orders the following laboratory studies:

$$\begin{aligned} &\text { Laboratory Test Results }\\ &\begin{array}{ll} \text { Fasting glucose } & 184 \mathrm{mg} / \mathrm{dL} \\ \text { HbA1C } & 8.8 \% \\ \text { Total cholesterol } & 256 \mathrm{mg} / \mathrm{dL} \\ \text { Triglycerides } & 346 \mathrm{mg} / \mathrm{dL} \\ \text { LDL } & 155 \mathrm{mg} / \mathrm{dL} \\ \text { HDL } & 32 \mathrm{mg} / \mathrm{dL} \\ \text { UA } & +\text { glucose, -ketones } \end{array} \end{aligned}$$

What are the risk factors for type $2$ DM? Place a star or asterisk next to those that Y.L. exhibits.

Y.L., a 34-year-old Southern Asian woman, comes to the clinic with complaints of chronic fatigue, increased thirst, constant hunger, and frequent urination. She denies any pain, burning, or low-back pain on urination. She tells you she has a vaginal yeast infection that she has treated numerous times with over-thecounter medication. She works full time as a clerk in a loan company and states she has difficulty reading numbers and reports, resulting in her making frequent mistakes. She says, "By the time I get home and make supper for my family, then put my child to bed, I am too tired to exercise." She reports her feet hurt; they often "burn or feel like there are pins in them." She has a history of gestational diabetes and reports that after her delivery she went back to her traditional eating pattern, which is high in carbohydrates. In reviewing Y.L.'s chart, you note she last saw the provider 6 years ago after the delivery of her last child. She has gained considerable weight; her current weight is 173 pounds. Today her blood pressure (BP) is 152/97 $\mathrm{mm} \mathrm{Hg}$, and a random plasma glucose level is $291 \mathrm{mg} / \mathrm{dL}$. The provider suspects that Y.L. has developed type 2 diabetes mellitus (DM) and orders the laboratory studies shown in the chart.

$$\begin{aligned} &\text { Laboratory Test Results }\\ &\begin{array}{ll} \text { Fasting glucose } & 184 \mathrm{mg} / \mathrm{dL} \\ \text { Hemoglobin } \mathrm{A}_{1 \mathrm{c}}\left(\mathrm{HbA}_{1 \mathrm{c}}\right. \text { ) } & 8.8 \% \\ \text { Total cholesterol } & 256 \mathrm{mg} / \mathrm{dL} \\ \text { Triglycerides } & 346 \mathrm{mg} / \mathrm{dL} \\ \text { Low-density lipoprotein (LDL) } & 155 \mathrm{mg} / \mathrm{dL} \\ \text { High-density lipoprotein (HDL) } & 32 \mathrm{mg} / \mathrm{dL} \\ \text { Urinalysis (UA) } & +\text { glucose,-ketones } \end{array} \end{aligned}$$

Identify the three methods used to diagnose DM.

How does bulimia nervosa differ from anorexia nervosa?

You are a nurse on an inpatient psychiatric unit. J.M., a $23$-year-old woman, was admitted to the psychiatric unit last night after assessment and treatment at a local hospital emergency department (ED) for "blacking out at school." She has been given a preliminary diagnosis of anorexia nervosa. As you begin to assess her, you notice that she has very loose clothing, she is wrapped in a blanket, and her extremities are very thin. She tells you, "I don't know why I'm here. They're making a big deal about nothing." She appears to be extremely thin and pale, with dry and brittle hair, which is very thin and patchy, and she constantly complains about being cold. As you ask questions pertaining to weight and nutrition, she becomes defensive and vague, but she does admit to losing "some" weight after an appendectomy $2$ years ago. She tells you that she used to be fat, but after her surgery she didn't feel like eating and everybody started commenting on how good she was beginning to look, so she just quit eating for a while. She informs you that she is eating lots now, even though everyone keeps "bugging me about my weight and how much I eat." She eventually admits to a weight loss of "about $40$ pounds and I'm still fat."

J.M.'s ECG results show normal sinus rhythm with no ST segment or other changes. You meet with J.M. to formulate a plan of care.

In general, the care plans for patients with anorexia are detailed and include many psychological aspects. What are they? You should be able to name at least $10$.

J.J. asks you whether there are other things he can do, in addition to medications, to help his anxiety. He tells you that he's heard about relaxation therapy and wants to hear more about it.
What would you discuss with J.J. about relaxation therapy?

It is $1000$ hours in the emergency department (ED) when the ambulance brings in G.G., a $35$-year-old man who is having difficulty breathing. He complains of chest pain and tightness, dizziness, palpitations, nausea, paresthesia, and feelings of impending doom and unreality; he is having trouble thinking clearly. He tells you, "I don't think I'm going to make it. I must be having a heart attack." He is diaphoretic and trembling. His vital signs are $184 / 92,104,28,98.4^{\circ} \mathrm{F}\left(36.9^{\circ} \mathrm{C}\right)$. This episode began at work during a meeting at approximately 0920 and became progressively worse. A co-worker called $911$ and stayed with the patient until medical help arrived. The patient has no history of cardiac problems.

What techniques to help him cope will you discuss with him?